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Headaches: Tension-Type

* Please note that most treatment modalities listed below are based on conventional medicine. PreventDisease.com does advocate the use of any pharmaceutical drug treatments. Long-term drug therapy is detrimental to human health. All drug information is for your reference only and readers are strongly encouraged to research healthier alternatives to any drug therapies listed.

WHAT IS TENSION-TYPE HEADACHE?

General Definition of Headaches

The brain itself is insensitive to pain. Headache pain occurs in the following locations:

The tissues covering the brain.
The attaching structures at the base of the brain.
Muscles and blood vessels around the scalp, face, and neck.

Headache is generally categorized as primary or secondary.

Primary Headache. A headache is considered primary when a disease or other medical condition does not cause it.

Tension headache is the most common primary headache and accounts for 90% of all headaches.
Migraines are the next most common prevelant headache. It is a very complex brain disorder, which involves a complicated interaction of nerve cells and blood vessel dilation. [ See Box Other Primary Headaches.]

Secondary Headache. Secondary headaches are caused by other medical conditions, such as sinusitis infection, neck injuries or abnormalities, and stroke. About 2% of headaches are secondary headaches caused by abnormalities or infections in the nasal or sinus passages (sinus headaches). [ See Box Causes of Secondary Headache.]

It is not uncommon for someone to experience a combination of headache types.

Tension-Type Headache

General Description. Tension-type headache (also called muscle contraction headache) is the most common of all headaches. It may have the following characteristics:

Tension-type headache is often experienced in the forehead, in the back of the head and neck, or in both regions.
It is commonly described as a tight feeling, as if the head were in a vise. Soreness in the shoulders or neck is common.
Depression, anxiety, and sleeping problems may accompany persistent headaches.
Sufferers of tension-type headaches are more sensitive to light than the general population, even between attacks. They also may suffer from visual disturbances. (Neither of these symptoms is as intense as in people with migraines. Tension-type headaches also do not cause nausea or limit activities as migraine headaches do.)
Tension-type headaches can last minutes to days.

Chronic Daily Headaches. The International Headache Society has developed a classification called chronic daily headache, which includes tension headache and is any benign headache that occurs more than 15 days a month and is not associated with a serious neurologic abnormality. Chronic, daily headaches affect about 4% to 5% of the population.

Chronic daily headache is, in turn, subdivided into two categories:

Short-duration headaches (those lasting less than four hours). The most common short-acting chronic headaches are cluster headaches.
Long-duration (lasting more than four hours). Tension-type headaches are the most common long-duration chronic headaches, and, in fact, the most common chronic headaches in general.

CAUSES OF SECONDARY HEADACHES

About 90% of people seeking help for headaches have a primary headache disorder. The balance of secondary headaches, however, is caused by an underlying disorder that produces the headache as a symptom. Many conditions cause headache as a symptom. There are over 300 disorders that can cause secondary headaches. Some of the most common are listed below.

Sinus Headache. Many primary headaches, including migraine, are misdiagnosed as sinus headache. Sinus headaches can occur in the front of the face, usually around the eyes, across the cheeks, or over the forehead. They are usually mild in the morning and increase during the day and are usually accompanied by fever, runny nose, congestion, and general debilitation. Sinus headaches spread over a larger area of the head than migraines, but it is often difficult to tell them apart, particularly if headache is the only symptom of sinusitis; they even coexist in many cases. Often, the visual changes associated with migraine can rule out sinusitis, but such visual changes do not occur with all migraines. (In rare cases, sinusitis can cause double vision and even vision loss, a sign of very serious infection.) [For more information, see the Report #62, Sinusitis.]

Headaches that Originate in the Neck. Some headaches may be caused by abnormalities of the neck muscles (called cervicogenic headaches). Nerves in the neck converge in the trigeminal nerve. This is the largest nerve in the skull. It originates in the brain stem and supplies sensation to the face. This nerve can generate pain signals to the facial area that the brain may interpret as headache. Pain is usually on one side; even if it affects both sides of the head it is usually more severe on one side. The quality of the headache may be difficult to distinguish from an aching tension headache or a mild migraine without aura. Cervicogenic headaches can result from prolonged poor posture (such as that caused by sitting in front of a computer keyboard or driving daily for long periods), arthritis, injuries of the upper spine, or abnormalities in the cervical spine (the spinal bones in the neck). Whiplash injuries involve the neck and can cause constant tension headaches, which, according to a 2001 British study, resolve within three weeks in 85% of patients.

Temporomandibular Joint Dysfunction (TMJ). TMJ is caused by clenching the jaws or grinding the teeth (usually during sleep), or by abnormalities in the jaw joints themselves. The diagnosis is easy if chewing produces pain or if jaw motion is restricted or noisy. TMJ pain can occur in the ear, cheek, temples, neck, or shoulders.

Glaucoma. Acute glaucoma is caused by increased pressure in the eye and requires immediate medical attention. Throbbing pain may be felt around or behind the eyes or in the forehead. Patients have redness in the eye and may see halos or rings around lights.

Brain Tumor. Fear of brain tumor is common among people with headaches, but headache is almost never the first or only sign of a tumor. Changes in personality and mental functioning, vomiting, seizures, and other symptoms are more likely to appear first. When the headache does develop, it is often worse early in the morning or may awaken sufferers during the night.

Neuralgia. Neuralgia is pain due to nerve abnormalities, which can occur in the facial area and resemble migraine or sinus headaches.

Hypertension. Although many people attribute headaches to high blood pressure, the two are rarely associated. An exception is malignant hypertension, an uncommon medical emergency, in which the blood pressure abruptly rises to extreme levels, causing damage to blood vessels in the brain, heart, and kidneys.

Strokes Caused by Blood Clots or Hemorrhages. A blood clot or hemorrhage in the brain leading to a stroke can cause a severe headache, sometimes referred to as a thunderclap headache when it is very sudden and severe. The onset of such a headache, particularly if it is associated with confusion, stupor, or other neurologic symptoms, mandates prompt medical attention. It is important to determine if a clot or bleeding is causing the stroke, since treatments are very different.

Head Injuries. It is obvious that a significant blow to the head will cause pain. In most cases, the pain is similar to tension-type headache and is treated in the same ways. Post-injury headaches, however, can reflect serious damage, ranging from skull fractures to internal bleeding, and monitoring is important.

Disorders of the Meninges. The meninges are the membranes covering the brain and the spinal cord. In very rare instances, ordinary physical strain may injure or weaken the meninges, causing a leakage of cerebrovascular fluid (the fluid that bathes the brain). This can cause severe headache and nausea, which are relieved by lying flat. The condition is very treatable. Meningitis, which is an infection or irritation of these membranes, is an uncommon but potentially serious cause of severe headache. Other symptoms include nausea and stiffness or pain in the neck.

Gynecologic Problems. Many clinicians have anecdotally linked gynecologic problems, such as ovarian cysts and menstrual disorders, to chronic headaches, and new data are emerging to support this association.

Temporal (Giant Cell) Arteritis. Certain causes of headaches are unique to the elderly, such as temporal arteritis, also called giant cell arteritis. Inflammation in arteries that carry blood to the head, neck, and sometimes the upper part of the body can cause very severe headaches. The risk for this headache is highest in people over age 70, especially among women, people of European heritage, and patients with polymyalgia rheumatica.

Miscellaneous Causes of Benign Headaches. Rapid consumption of ice cream or other very cold foods or beverages is the most common trigger of sudden headache pain, which may be prevented by warming the food or drink for a few seconds in the front of the mouth before swallowing. Other common benign causes of headache include eyestrain, dental problems, allergies, systemic infections, and caffeine withdrawal. Headaches may be induced by sexual activity or intense physical exertion.

HOW SERIOUS ARE TENSION-TYPE HEADACHES?

Although they are not medically dangerous, the negative impact of chronic tension headaches on quality of life, families, and even work productivity can be significant and is generally underrated by the health profession.

In one 2000 study, two-thirds of patients with chronic tension-type headaches reported daily or near daily headaches for an average of seven years. Only 12% reported headaches occurring less than 20 days a month. In the study, 74% of the patients had to take some time off from work because of the headaches, and about a third reported impaired sleep, energy, and reduced emotional well-being on 10 or more days a month. Most were able to carry out their daily responsibility even when in pain, although at lower than normal capacity. This and other studies report a strong association between anxiety and depression and chronic tension-type headaches.

One group of researchers studied the ability of people with chronic headaches to cope during an attack. Those with tension-type headaches tended to have higher anxiety and lower quality of life than people with migraines (who, however, were less able to cope during a headache). People with any chronic, persistent headache had more psychological disabilities than those who experienced only episodic headache.

WHAT CAUSES TENSION AND OTHER CHRONIC DAILY HEADACHES?

Because of its high prevalence, tension-type headache is among the most costly diseases in the US; given this, it is surprising that so little scientific attention has been focused on determining the cause or causes of this widespread problem. There does not appear to be a single cause of chronic tension-type headache but many factors are involved in causing the disorder.

Muscle Contractions

The basic source of tension-type headaches is most likely muscle contraction in the head, neck, and shoulders. Reduced blood flow in the tensed areas may result in the buildup of metabolic waste products in the tissues that irritate the tissues, which, in turn, cause the pain of headache. Pain can last long after the muscles have relaxed. Tension-type headache may be either an acute response to specific events or a chronic syndrome caused by repeated or continuing states of muscle contraction. Little is known what really causes such contractions.

Increased Muscle Tenderness and Sensitivity to Pain

Studies have suggested that tension-type headache sufferers may have higher-than-average muscle tenderness in the face and head that make them more susceptible to headache after muscle contractions. A few studies suggest that some patients with chronic headaches may be overly sensitive to pain in general or may overestimate muscle contraction pain.

Biologic Factors

Serotonin Levels. Serotonin is a neurotransmitter (chemical messenger in the brain) that is important for sleep, well being, and other factors that affect quality of life. Abnormalities in serotonin levels have also been observed in tension headache sufferers.

Nitric Oxide. Nitric oxide is a substance that helps blood vessels relax and open. There is some evidence that the release of this molecule may play a role in most primary headaches (tension-type, cluster, and migraine.) The mechanisms for this possible effect, however, are still unknown.

Gynecologic Factors. Women can experience persistent headaches during periods of hormonal changes, including menstruation, at the beginning or end of pregnancy, and menopause. Many clinicians have also anecdotally linked gynecologic problems, such as ovarian cysts and menstrual disorders, to chronic headaches, and data are emerging to support this association.

Temporomandibular Joint Dysfunction (TMJ). Muscle contractions that cause headaches may be a result of temporomandibular joint dysfunction, which is caused by clenching the jaws or grinding the teeth (usually during sleep), or by abnormalities in the jaw joints themselves.

Genetic Factors

Genetic factors appear to play a role in predisposing people to recurrent tension headaches. One study of twins suggested that the chances of inheriting the susceptibility to recurring headaches (both migraine and tension) were about 70% in close relatives. The trait is equal in both boys and girls. Because such headaches tend to occur in females, however, other factors, such as hormonal, social, or psychological, must play a role in their development.

Stress and Psychological Factors

Tension-type headache has been highly associated with an intense response to stress. Some studies suggest that patients with chronic tension-type headaches have more general feelings of anxiety or depression, and a 2001 study indicated that patients with tension headaches tend to perceive every day events as more stressful than those without headaches do. Some research even suggests that tension-type headache victims may have some biological predisposition for translating stress into muscle contraction. Still, the link between stress and tension-type headaches is not fully known and some evidence challenges any causal association.

Other Causes of Chronic Daily Headaches

Rebound, or Drug-Induced, Headache. Many persistent headaches are actually the result of the rebound effect caused by the overuse of headache medications. Usually in such cases, medications have usually been taken on an ongoing basis for more than three days each week. If patients stop taking these drugs, the headaches come back (which are referred to as rebound headaches). The patient then starts taking the drugs again. Eventually the headache simply persists and medications are no longer effective. Even after successful withdrawal, relapse is common, particularly with medications that contain caffeine. In one study nearly half of patients relapsed within four years and developed full-blown relapse headaches again.

Medications implicated in rebound headache include simple painkillers (eg, aspirin, ibuprofen), barbiturates, sedatives, narcotics, and migraine medications, particularly those that also contain caffeine. (Heavy caffeine use can also cause this condition.) [For more information see the Report #97, Migraine.]

Transformed Migraines. In some cases, migraines naturally evolve into chronic, daily headaches referred to as transformed migraines. [For more information see the Report #97, Migraine.]

Head Injury. One study of patients who had chronic headaches after suffering an injury reported that the symptoms were similar to patients with chronic headaches of unknown cause. More men than women had post-traumatic headache, which is a reversal of the tension-headache gender ratio. Experts believe this might suggest actual changes in brain function. However, it is not known whether liability and worker's compensation issues may have some effect on the persistence of some of these headaches.

WHO GETS TENSION AND CHRONIC DAILY HEADACHES?

Prevalence and General Risk Factors

Tension-type headaches account for about two-thirds of all headaches. Almost 40% of Americans have episodes of tension-type headache each year, and virtually everyone experiences tension-type headache at some point in their life.

Surveys indicate that about up to 5% of people have chronic tension-type headaches, which can last up to several weeks. Those at highest risk are middle-aged women, Caucasians, and people who are well educated. International studies suggest that the prevalence is high and risk factors are similar in any developed country, in both the East and the West.

Headaches in Young People

Tension-type headaches usually begin in adulthood, but can occur in childhood as well. In one large 2001 British study, about 8% of children age seven and 15% of 11 year olds had headaches. Headaches occurred most frequently around age 13, however. And, 10% of child sufferers had recurrent headaches. The study further reported that many of these children tended to have headaches and other physical complaints when they grew up. In the study, significant factors associated with childhood headaches included:

Moderate or severe depression.
Separation from the mother for more than a week.
Chronic illness in the mother when the child was younger than 11.
Mental illness in any family member.

Yet another 2001 study reported that young people with headaches tended to be more emotionally rigid and to have repressed anger than their peers.

Some Specific Risk Factors for Tension-Type Headaches

The following conditions can make people susceptible to tension-type headaches.

Chronic poor posture.
Chronic Overwork.
Upper respiratory tract infections, such as colds and flus, can produce tension-type headache. In fact, according to one 1999 study, tension-type headache in children is most often associated with such infections.
Sleep disorders, such as insomnia or sleep apnea, may contribute to tension headache, particularly those that occur at night or early morning. (In one study, for example, treating people who had chronic headaches for sleep apnea cured the headaches in many cases.)
Hypothyroidism, or decreased thyroid function.
Dental problems.
Allergies.
Substance or alcohol abuse.

Triggers for Tension-Type Headache Episodes

Certain triggers, including the following, may cause headache episodes in people with chronic tension-type headaches:

Specific stressful events.
Not eating on time.
Fatigue.
Lack of sleep.
Withdrawal from over-used substances (caffeine, nicotine, alcohol, pain relievers).
Eyestrain.
Intense physical exertion (including sexual activity). Athletes are at higher risk for headaches. (A sedentary lifestyle, however, may increase the risk for stress and thereby also be a risk factor for tension headaches.)

Of interest, the rapid consumption of ice cream or other very cold foods or beverages is a well-known trigger of sudden headache pain, the so-called "ice cream" headache. It can be easily prevented by warming the food or drink for a few seconds in the front of the mouth before swallowing.

HOW IS TENSION-TYPE HEADACHE DIAGNOSED?

Ruling Out Other Common Headaches

Diagnosing the cause of persistent daily headache is difficult, even for expert physicians. It is important to choose a doctor who is sensitive to the needs of headache sufferers and aware of the latest advances in treatment. Tension-type headache, although the most common chronic daily headache, is usually diagnosed after ruling out other types. [ See Boxes Causes of Secondary Headaches and Other Primary Headaches.]

Medical and Personal History

For an accurate diagnosis, the patient should describe the following:

Duration and frequency of headaches.
Recent changes in their character.
The location of the pain.
The type (eg, throbbing or steady pressure).
The intensity of the headache.
Associated symptoms, such as visual disturbances or nausea and vomiting. (These are seen most often with migraines.)
Behaviors during a headache. (This may help distinguish between migraine and tension headaches. For example, a person with migraines is more apt to perform maneuvers to relieve pain, such as applying cold packs, trying various reclining or sitting positions, using more pillows then usual, inducing vomiting, and become very still or isolated. The predominate behavior with tension headaches is massaging the scalp.)

Headache Diary to Identify Triggers

The patient should try to recall what seems to bring on the headache and anything that relieves it. Keeping a headache diary is a useful way to identify triggers that bring on headaches. Some tips include the following:

Be sure to include all events preceding an attack. Often two or more triggers interact to produce a headache. Experts are investigating triggers of headaches to determine if certain ones are more likely to set off different primary headaches. In general, however, the same stimuli seem to trigger any of the primary headaches, although people with migraines may be more sensitive to some of them (eg, weather, certain smells, light, and smoke) than people with tension headaches.
Tracking medications is an important way of identifying rebound headache or transformed migraine.
Be sure to attempt to define the intensity of the headache. It may be indicated by using a number system:

1 = mild, barely noticeable.

2 = noticeable, but does not interfere with work/activities.

3 = distracts from work/activities.

4 = makes work/activities very difficult.

5 = incapacitating.

Medical and Personal History

The patient should report any other conditions that might be associated with headache, including but not limitedto the following:

Any chronic or recent illness and their treatments.
Any injuries, particularly head or back injuries.
An uncharacteristic dietary changes.
Any current medications or recent withdrawal from any drugs, including over-the-counter or so-called natural remedies.
Any history of caffeine, alcohol, or drug abuse.
Any serious stress, depression, and anxiety.

The physician will also need a general medical and family history of headaches or diseases, such as epilepsy, that may increase their risk. Migraine, in particular, tends to run in families.

Physical Examination

In order to diagnose a chronic headache, the physician will examine the head and neck and will usually perform a neurologic examination, which includes a series of simple exercises to test strength, reflexes, coordination, and sensation. The physician may ask questions to test short-term memory and related aspects of mental function.

Imaging Tests

Imaging tests of the brain may be recommended under the following circumstances:

If the results of the history and physical examination suggest neurologic problems.
For patients with headache that wakes them at night.
For new headaches in the elderly. In this age group, it is particularly important to first rule out age-related disorders, including stroke, hypoglycemia, hydrocephalus, and head injuries (usually from falls).
For patients with worsening headache.

They are not recommended for patients with migraine and with no other abnormal indications. [ See Box, Headache Symptoms that Could Indicate Serious Underlying Disorders.]

The following tests may be used:

A CT (computed tomography) scan may be ordered to rule out brain disorders or headaches caused by chronic sinusitis.
X-rays and other tests may also be used if sinusitis is strongly suspected.
A neck x-ray can reveal arthritis or spinal problems.
Other tests include an MRI (magnetic resonance imaging), EEG (electroencephalogram), lumbar puncture, ultrasound testing, and cerebral angiography, which are only performed if there is reason to suspect an underlying disease.

Headache Symptoms that Could Indicate Serious Underlying Disorders

Headaches indicating a serious underlying problem, such as cerebrovascular disorder or malignant hypertension, are uncommon. (It should again be emphasized that a headache is not a common symptom of a brain tumor.) People with existing chronic headaches, however, might miss a more serious condition believing it to be one of their usual headaches. Such patients should call a physician promptly if the quality of a headache or accompanying symptoms has changed. Everyone should call a physician for any of the following symptoms:

Sudden, severe headaches that persist or increase in intensity over 24 hours.
Sudden, very severe headache, worse than any headache ever experienced (possible indication of stroke caused by bleeding, with a hemorrhage or a ruptured aneurysm).
Chronic or severe headaches that begin after age fifty.
Headaches accompanied by memory loss, confusion, loss of balance, changes in speech or vision, or loss of strength in or numbness or tingling in arms or legs.
Headaches after head injury, especially if drowsiness or nausea are present (possibility of hemorrhage).
Headaches accompanied by fever, stiff neck, nausea and vomiting (possibility of spinal meningitis).
Headaches that increase with coughing or straining (possibility of brain swelling).
A throbbing pain around or behind the eyes or in the forehead accompanied by redness in the eye and perceptions of halos or rings around lights (possibility of acute glaucoma, which is excessive eye pressure).
A one-sided headache in the temple in elderly people; the artery in the temple is firm and knotty and has no pulse; scalp is tender a headache that is more likely in elderly people, particularly those with polymyalgia rheumatica, and is due to abnormal immune functioning. Untreated, it can cause blindness or even stroke).
Sudden onset and then persistent, throbbing pain around the eye possibly spreading to the ear or neck unrelieved by pain medication (possibility of blood clot in one of the sinus veins of the brain).

WHAT ARE THE GENERAL GUIDELINES FOR MANAGING TENSION-TYPE HEADACHES?

Given the very high prevalence of tension-type headaches, some experts express frustration over the dearth of serious scientific attention given to this problem.

Guidelines for Acute Tension-Type Headaches

Fortunately, most acute tension-type headaches resolve on their own without any treatments, and simple over-the-counter pain relievers are sufficient for mild symptoms. The most common pain relievers are the following:

Acetaminophen (Tylenol, Anacin-3, Panodal, Phenaphen, and Valadol).
Over-the-Counter Nonsteroidal Anti-inflammatory Drugs (NSAIDs). Over-the-counter NSAIDs include aspirin, ibuprofen (Motrin IB, Advil, Nuprin, Rufen), naproxen (Aleve), ketoprofen (Actron, Orudis KT). One study suggested that ibuprofen or naproxen is more effective than aspirin or acetaminophen for acute tension-type headache.
Prescription NSAIDs. The include ibuprofen (Motrin), naproxen (Naprosyn, Anaprox, diclofenac (Voltaren), tolmetin (Tolectin), ketoprofen (Orudis, Oruvail).

In one study, acetaminophen worked only slightly better than placebo (a dummy pill). A NSAID was also used in the study (ketoprofen) and was significantly more effective in relieving pain. Ketoprofen is a prescription agent, however, that carries a higher risk for gastrointestinal symptoms than either acetaminophen or over-the-counter NSAIDs, which were not tested in this study, but should be tried first.

Guidelines for Chronic Tension-Type Headache

There are few proven therapies for treating or preventing chronic tension-type headaches, however, and studies are weak. The value of most treatments is known only from reports of physician experiences, not scientific data. Only antidepressants have been extensively studied. Some researchers suggest the following:

Because many chronic daily headaches are due to over-use of headache medications, withdrawal from such agents is the first action. (NSAIDs or other painkillers should not be used to prevent chronic tension-type headache.)
Psychologic methods, including cognitive behavioral therapies, relaxation, and stress-reduction techniques, should be used throughout for managing headaches. They should be the first option for children and adolescents with chronic headache.
If medication withdrawal and psychologic methods fail to bring improvement, tricyclic antidepressants are used next. In one 2001 study, patients with chronic daily tension headache who were given tricyclics reported greater improvement after a month than those who were given stress management techniques. The combination of the two approaches worked even better. (At six months, however, stress management was as effective as the antidepressants in improving headaches.) [ See What Are the Medications for Tension-Type Headaches? .]
Physical therapies or acupuncture may help some people.

Withdrawing from Medications after Rebound Headaches

If rebound headaches develop because of medication overuse, the patients cannot recover without stopping the drugs. (If caffeine is the culprit, a person may only need to reduce coffee or tea drinking to a reasonable level, not necessarily stop drinking it altogether.) The patient usually has the option of stopping abruptly or gradually and should expect the following course:

Most headache drugs can be stopped abruptly but the patient should be sure to check with the physician before withdrawal. Certain non-headache medications, such as anti-anxiety drugs or beta-blockers, require gradual withdrawal.
If the patient chooses to taper off standard headache medications, withdrawal should be completed within three days or shorter. Otherwise the patient may become discouraged.
No matter which approach is used for stopping medication, the patient must expect a period of worsening headache for a few days afterward. Alternative pain relievers may be administered during the first days to help withdrawal.
Most people feel better within two weeks, although headache symptoms can persist up to 16 weeks (and in rare cases even longer).

On the encouraging side, some patients experience dramatic long-term relief from all headaches afterward, and one study reported that 82% of patients significantly improved four months after withdrawal.

WHAT ARE THE MEDICATIONS FOR TENSION-TYPE HEADACHES?

Pain Relievers for Mild to Moderate Headaches

NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) block prostaglandins, substances that dilate blood vessels and cause inflammation. NSAIDs are usually the first drugs tried for almost any kind of headache. There are dozens of NSAIDs. Aspirin is the most common, but is not as effective for acute tension-type headache as others. They include ibuprofen (Advil, Motrin, Rufen), indomethacin (Indocin), naproxen (Aleve, Naprosyn, Naprelan, Anaprox), ketoprofen (Orudis, Oruvail), piroxicam (Feldene), oxaprozin (Daypro), sulindac (Clinoril), tolmetin (Tolectin), meclofenamate (Meclomen), and ketorolac (Toradol).

Acetaminophen. Acetaminophen (Tylenol, Anacin-3, Panodal, Phenaphen, and Valadol) is a good alternative to NSAIDs when stomach distress, ulcers, or allergic reactions prohibit their use. Midrin (a combination of an agent that narrows blood vessels, a mild sedative, and acetaminophen) may be particularly useful for tension-type headaches.
COX-2 Inhibitors. Celecoxib (Celebrex), rofecoxib (Vioxx), and valdecoxib (Bextra) are known as COX-2 (cyclooxygenase-2) inhibitors. They may prove to be beneficial for chronic tension-type headache without incurring as high risk for ulcers and bleeding.

Antidepressants

Antidepressants may be useful in preventing tension-type headaches. Those known as the tricyclics and monoamine oxidase inhibitors are the gold standard for prevention of severe chronic tension-type headaches. Others, known as SSRIs, are also sometimes used in milder cases.

Tricyclic Antidepressants. Tricyclics are useful not only for depression but appear to help relieve muscle pain and improve sleep as well. One study reported that these agents may actually reduce the transmission of pain to the nerves in the face.

The tricyclic drug most commonly used is amitriptyline (Elavil, Endep), which produces modest benefits with pain, but which can lose effectiveness over time. Other tricyclics include desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), trazodone (Desyrel), and nortriptyline (Pamelor, Aventyl).

Side effects are fairly common with these medications, and those most often reported include dry mouth, constipation, blurred vision, sexual dysfunction, weight gain, difficulty in urinating, disturbances in heart rhythm, drowsiness, and dizziness. Blood pressure may drop suddenly when sitting up or standing. Tricyclics can have serious, although rare, side effects. Overdose can be fatal. Tricyclics may pose a danger for some patients with certain heart diseases. One study comparing nortriptyline with paroxetine, an SSRI, reported nine times more adverse cardiac events with the use of the tricyclic than with the SSRI. Also of concern is a study reporting that tricyclics, particularly imipramine, may be responsible for 10% of cases of a lung disease called idiopathic pulmonary fibrosis (IPF), which can cause lung inflammation and scarring. Initial symptoms are breathlessness and dry cough. The two newer tricyclics, mianserin and dothiepin, also increase the risk.

Monoamine Oxidase Inhibitors (MAOIs). Monoamine oxidase inhibitors (MAOIs) include phenelzine (Nardil), isocarboxazid (Marplan), and tranylcypromine (Parnate). The most common side effects are orthostatic hypotension (a sudden drop in blood pressure upon standing), drowsiness, dizziness, sexual dysfunction, and insomnia. The most serious side effect is severe hypertension (high blood pressure), which can be brought on by eating certain foods having a high tyramine content. Such foods include aged cheeses, most red wines, sauerkraut, vermouth, chicken livers, dried meats and fish, canned figs, fava beans, and concentrated yeast products. MAOIs may also cause birth defects and should not be taken by pregnant women. MAOIs can have serious interactions with a number of drugs, including some common over-the-counter cough medications, psychostimulants (such as Ritalin), and decongestants. Very dangerous side effects can occur from interactions with other antidepressants, including SSRIs. There should be at least a two to five week break between taking MAOIs and other antidepressants.

Selective Serotonin-Reuptake Inhibitors. Selective serotonin-reuptake inhibitors (SSRIs) work by increasing levels of serotonin in the brain. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), and citalopram (Celexa). Because they act on serotonin specifically, they have fewer side effects than the older antidepressants, which affect a number of chemicals in the body. SSRIs take two to four weeks to be effective in most adults and longer, up to 12 weeks, so their value in headache is limited. In one study, however, Prozac was more effective than a tricyclic for patients with headache who were not depressed. Side effects include nausea, gastrointestinal problems, agitation, insomnia, mild tremor, impulsivity, temporary weight loss, and sexual dysfunction. Death from overdose is extremely rare. Serious interactions can occur with other antidepressants, such as tricyclics and, of particular note, MAOIs.

Designer Antidepressants. A number of drugs have now been developed that target other neurotransmitters, such as norepinephrine, alone or in addition to serotonin, and are showing promise for prevention of tension-type headache. The following are some examples:

In one study bupropion (Wellbutrin) was as effective as a tricyclic in preventing tension-type headaches.
Nefazodone (Serzone), a fast-acting designer antidepressant, was particularly beneficial in a 2001 study. After three months of treatment over 70% experienced a reduction in headache symptoms by at least half and nearly 60% reported symptoms improvements of over 75%.

Antianxiety Agents

Mild antianxiety agents are occasionally used as an adjunct in treating chronic headaches to decrease muscle contraction or to treat anxiety symptoms during periods of extreme stress. They include alprazolam (Xanax) and clonazepam (Klonopin). They tend to be highly addictive, however, and should therefore be used only on a short-term basis.

Opioids

Opioids, such as codeine or propoxyphene, are sometimes prescribed for severe headaches, although their use is controversial because of the risk for addiction. A small group of patients with severe, chronic headache may be candidates for daily long-term opioid treatments, for example combinations of drugs containing acetaminophen and codeine (Axocet and Fioricet). Methadone is showing promise for patients who do not respond to standard treatments. These agents are narcotics, however and may be subject to abuse. Patients must be monitored and reevaluated regularly. Overuse of these drugs can reduce their effectiveness and lead to rebound headaches, so physician involvement is essential. Long-term, high-dosage use of some of these drugs can also lead to kidney disease and ulcers. Other, less serious side effects include gastrointestinal upset, dizziness, and ringing in the ears (tinnitus).

Other Drugs Being Tested for Treating Chronic Tension-Type Headache

Valproate. In some studies the anticonvulsant medication, valproate, has been effective for stopping headaches in some patients with persistent migraines and tension-type chronic daily headaches. In one study, 75% of patients with either type of headache experienced at least a 50% reduction in headache frequency and severity. Minor side effects occurred in a third of the patients. Other anti-seizure medications are under investigation.

Botulinum Toxin. Botulinum toxin A (Botox) injections are now widely used to relax muscles and reduce skin wrinkles. They are also being investigated for chronic headaches. (This potentially deadly toxin is very safe when minuscule amounts are injected into small muscles.) Botulinum has been promising for migraine sufferers, but there is considerable debate about its effectiveness for chronic tension-type headaches. A 2001 report suggested that the weight of current evidence supported its use, although individual studies have had contradictory results, with some reporting no benefit. More research is needed.

Tizanidine. Tizanidine (Zanaflex) is an agent called an alpha2-adrenergic agonist. It blocks the release and effectiveness of a stress chemical in the body and may also help prevent muscle spasms. Early studies in 2000 and 2001 are reporting that nearly 70% of patients with chronic tension-type headache are experiencing a reduction in headache symptoms of 50% or more. Side effects are minor and include fatigue and dry mouth.

Herbal and Other Natural Remedies

A number of herbal remedies are promoted for tension-type headache. It is critical that anyone taking herbal or so-called natural remedies should be aware of the lack of regulations governing their quality and effectiveness. [ See Box Warnings on Alternative and So-Called Natural Remedies.]

Peppermint or Lavender Oil. Some patients find relief using two drops of peppermint or lavender oil added to one cup of water. The patient soaks a cloth in the solution and applies it as a compress to the head.

Other Herbs. Other herbs used in teas or as supplements for tension-type headache include feverfew (one of the few remedies seriously studied), white willow bark or meadowsweet (which contain chemicals found in aspirin), St. John's wort (an herbal antidepressant), valerian (which has sedative and anti-spasmodic properties), and ginkgo biloba (which may increase blood circulation to the brain). Because of the lack of data and unregulated nature of these products, none are recommended. No one should take these remedies without consulting a physician, particularly people on other medications or with chronic or serious medical conditions.

Warnings on Alternative and So-Called Natural Remedies

It should be strongly noted that alternative or natural remedies are not regulated and their quality is not publicly controlled. In addition, any substance that can affect the body's chemistry can, like any drug, produce side effects that may be harmful. Even if studies report positive benefits from herbal remedies, the compounds used in such studies are, in most cases, not what are being marketed to the public.

There have been a number of reported cases of serious and even lethal side effects from herbal products. In addition, some so-called natural remedies were found to contain standard prescription medication. Most problems reported occur in herbal remedies imported from Asia, with one study reporting a significant percentage of such remedies containing toxic metals.

Of note for patients with headache, L-Tryptophan, an amino acid (a protein precursor), and 5-hydroxy-L-tryptophan (5-HTP), a byproduct of L-tryptophan, are used to produce serotonin. Serotonin is a neurotransmitter (a natural chemical in the brain) that is important for sleep, positive moods, and for a number of other conditions essential for well being. There have been many claims and some studies reporting benefits of L-tryptophan and 5-HTP for insomnia, headache, and depression, although the evidence supporting these benefits is still weak. Impurities found in L-tryptophan diet supplements have caused eosinophilia-myalgia syndrome (EMS) in some people. EMS is a disorder that elevates certain white blood cells and was fatal in a few cases. Supplements containing L-tryptophan are currently banned in the United States by the FDA.

The following website is building a database of natural remedy brands that it tests and rates. Not all are available yet. http://www.ConsumerLab.com/

The Food and Drug Administration has a program called MEDWATCH for people to report adverse reactions to untested substances, such as herbal remedies and vitamins (call 800-332-1088).

WHAT PROCEDURES MAY BE TRIED FOR TENSION-TYPE HEADACHE?

Cervical Epidural Nerve Block

In cases where abnormalities or injuries in the cervical spine (the spinal bones in the neck) cause headaches, a cervical epidural nerve block may be beneficial in treating and preventing further pain. This procedure involves injecting small amounts of a corticosteroid and anesthetic into spaces between the vertebrae in the neck to block the nerves. Some patients have reported significant pain relief from this procedure.

Dental Adjustments

One interesting 1999 European study tested whether dental adjustment to help teeth bite down evenly might help some people with chronic headaches. The results indicated that dental adjustments may be helpful. People with an uneven bite and chronic headaches might consider discussing this option with their dentists.

Trigger Point Needling

In trigger point needling, the physician uses an instrument called a pressure algometer, finds the source of the headache pain (the trigger point), and injects a pain reliever directly into the site. The needle is then used to break up any fluid or scar tissue in the area. The patient is required to perform therapeutic exercises after the procedure. This treatment may sound worse than the headache itself, but studies are reporting success with it in treating tension-type headaches and some migraines.

Alternative Procedures

Acupuncture and Acupressure. Techniques using acupuncture points on the body have become popular for managing pain. And some are showing benefits.

Acupuncture. A major 2001 analysis of 26 trials of acupuncture suggested that it may have some benefit for tension headache, but the evidence to date is not completely convincing. Some studies comparing short-term acupuncture to sham procedures report no benefits. Long-term and well-conducted studies are needed.
Percutaneous Electrical Nerve Stimulation. A technique called percutaneous electrical nerve stimulation (PENS) uses low-level electrical pulses delivered through acupuncture needles into soft tissue. Patients are barely aware of the sensation. In a 2000 study, patients with chronic tension, migraine, and post-injury headache were treated using either PENS or just needles. After six months of such treatments, those using PENS reported reductions in pain score of nearly 60% in migraine and tension-type headaches and 52% in injury-related headache, which was significantly greater than the needles alone. Energy levels and quality of sleep also improved.
Acupressure. One acupressure practitioner reports that pressing for 60 seconds on the web space between the forefinger and thumb of the dominant hand erases headache in patients with migraine and tension-type headaches. The specific spot pressed should be the most tender point in the web area. The patient should then lie down for about 15 minutes.

Spinal Manipulation. A number of small studies have suggested that spinal manipulation by chiropractors or osteopaths may have some benefits for people with tension-type headache.

The Procedure. Although techniques vary, the basic approach is to manipulate and stretch the spine beyond an elastic barrier of resistance but not so far as to impair the structure. The vertebrae may be moved directly or by stretching a muscle, such as in the thigh. One 1998 study found that spinal manipulation had no benefit for patients with episodic tension-type headaches. Some practitioners argued that the specific techniques studied were not appropriate ones for tension-type headaches, that the study was too short (19 weeks), and only areas around the neck and upper body were manipulated in the study rather than the entire body, which may have provided more benefit. (Evidence is stronger on benefits of spinal manipulation for patients with headaches originating from nerve or muscular problems in the neck. In fact, some experts believe that tension-type headaches relieved by spinal manipulation are probably really caused by neck problems.)
Side Effects and Complications. Side effects of spinal manipulation include local or radiating discomfort, headache, and fatigue; they rarely last longer than 24 hours. It should be noted that there have been reports of stroke or blood clots after spinal manipulation in the neck area, even in people without a previous history of these events. Although these complications are rare, people should be aware of these dangers.

Reflexology

One 1999 alternative medicine study reported that reflexology, a method that manipulates the feet, was associated with improvement in 81% of patients with tension or migraine headaches. Patients reported an improvement in energy, well-being, and increased ability to understand the cause of the headaches. In the study, 19% went off medication.

WHAT ARE LIFE-STYLE AND PSYCHOLOGIC APPROACHES FOR TENSION-TYPE HEADACHES?

Good Health Habits

Good health habits, including adequate sleep, healthy diet, regular exercise, and good stress management are important, along with the following specific measures for headache management. Quitting smoking is essential in reducing the risks for all headaches.

Pressure, Heat, and Cold

An ancient and potentially effective remedy for tension headaches uses pressure applied to the head (such as a headband or a towel wrapped around the head) plus either heat or cold. In one 2000 study, 87% of headache sufferers experienced significant relief and the rest reported moderate relief while they were wearing special headbands that could be tightened. They applied packs that were frozen or microwaved. (Either heat or cold packs were useful, although people with tension headaches generally preferred cold packs.)

Ice Water. A novel treatment uses ice water that circulates for 15 minutes through metal tubes placed in the back of the jaw. In one small study, this procedure reduced pain in four out of six patients whose headaches were associated with neck problems.

Dietary Factors

A healthy diet rich in fresh fruits and vegetables and whole grains and low in saturated fats (animal fats) is important to everyone. Fish (particularly oily fish such as salmon and tuna) and soy are protein sources that may be a good alternative to red meats.

Caffeine. In some people with headaches, caffeine appears to be an excellent companion to medications. One study found that the caffeine equivalent of two and a half of cups of coffee can help treat a tension-type headache by itself. Taking ibuprofen along with caffeine is even more effective than either substance alone. (It should be noted that in some people with migraines, the tannin found in coffee or tea may be a trigger for the headache. In addition withdrawal from caffeine is a major cause of headache.)

Treatment of Sleep Disorders

Headaches that occur during the night and early morning may be related to sleep disorders. One study reported that treating an underlying sleep disorder, such as sleep apnea or insomnia in patients who also had headaches resulted in headache cure or improvement in all patients except those who suffered from restless legs syndrome. [For more information see the Reports #27, Insomnia and #65, Sleep Apnea .]

Relaxation and Related Stress Reduction Therapies

A number of stress-reduction methods are available that may help may help counteract the tendency for muscle contraction and uneven blood flow associated with some headaches. In choosing specific strategies for treating stress, several factors should be considered.

First, no single method is uniformly successful: a combination of approaches is generally most effective.
Second, what works for one person does not necessarily work for someone else.
Third, stress can be positive as well as negative. Appropriate and controllable stress provides interest and excitement and motivates the individual to greater achievement, while a lack of stress may lead to boredom and depression.

Among the stress reduction techniques that may be helpful are the following:

Guided imagery. (This uses body awareness and visualization of pleasant or positive images.)
Biofeedback. This technique works when patients develop awareness of their physical responses and learn to feed this information back to the brain for the purpose of replicating that response. It is often used to reduce muscle tension. One interesting and sometimes effective technique for headaches is called thermal biofeedback. It employs the idea that hand-warming reduces blood flow to the brain and so relieves headache. The patient learns techniques (such as using specific images) that can raise the temperatures of the hand during a headache. Studies suggest the approach has been helpful in children with tension and migraine headaches.
Muscle relaxation exercises.
Massage therapy.
Hypnosis.
Breathing exercises. Studies have reported that correct and rhythmic breathing from the diaphragm can sometimes relieve tension-type headaches. Such breathing exercises may be particularly beneficial when performed with physical movements. (Yoga, in fact, is a practice that combines both and has been helpful in people with headaches.)

Any of these therapies may be used in conjunction with drug therapy. Of interest was a 2001 Swedish study, which reported that relaxation techniques helped adolescents with migraine but not tension-type headache. [For more information see the Report 31, Stress.]

Musical Therapy

An interesting alternative therapy called medical resonance uses specific harmonic sounds to create rhythmic changes in blood flow in the brain. In one small study, all patients experienced relief during and after exposure to the music. Generally, individuals listen to it for fifteen to twenty minutes either first thing in the morning or in the evening.

OTHER PRIMARY HEADACHES

Migraine Headaches: General Description of its Course

Migraine is now recognized as a chronic illness, not simply as a headache. In general, there are four symptom phases to a migraine (although they may not all occur in every patient): the prodrome, auras, the attack, and the postdrome phase.

Prodrome. The prodrome phase is a group of vague symptoms that may precede a migraine attack by several hours, or even a day or two. Such prodrome symptoms can include the following:

Sensitivity to light or sound.
Changes in appetite.
Fatigue and yawning.
Malaise.
Mood changes.
Food cravings.

Auras. Auras are sensory disturbances that occur before the migraine attack occurs. Although some studies estimate that up to half of migraine sufferers have auras, some recent evidence suggests that only about 20% experience them. Visually, auras are referred to as being positive or negative.

Positive auras include bright or shimmering light or shapes at the edge of their field of vision called scintillating scotoma . They can enlarge and fill the line of vision. Other positive aura experiences are zigzag lines or stars.
Negative auras are dark holes, blind spots, or tunnel vision (inability to see to the side).
Patients may have mixed positive and negative auras. This is a visual experience that is sometimes described as a fortress with sharp angles around a dark center.

Other neurologic symptoms may occur at the same time as the aura, although they are less common. They include the following:

Speech disturbances.
Tingling, numbness, or weakness in an arm or leg.
Perceptual disturbances such as space or size distortions.
Confusion.

Migraine Attack. If untreated, attacks usually last from 4 to 72 hours. A typical migraine attack produces the following symptoms:

Throbbing pain on one side of the head. The word migraine, in fact, is derived from the Greek word hemikrania, meaning "half of the head" because the pain of migraine often occurs on one side. Pain also sometimes spreads to affect the entire head.
Pain worsened by physical activity.
Nausea, sometimes with vomiting.
Visual symptoms.
Facial tingling or numbness.
Extreme sensitivity to light and noise.
Looking pale and feeling cold.

Postdrome. After a migraine attack, there is usually a postdrome phase, in which patients may feel exhausted and mentally foggy for a while.

Cluster Headache

Cluster headaches are very painful events. Patients typically awaken a few hours after they go to sleep with the following symptoms:

Very severe, stabbing pain centered in one eye.
Excessive tearing, a drooping eyelid, and one stuffy or runny nostril, all on the same side as the pain.
Feelings of intense restlessness are common. People in the throes of a cluster headache may pace the floor or may even bang their heads against the wall in an attempt to cope with the pain.

Cluster headaches often have a cycle with the following pattern:

Attacks themselves are usually brief, lasting between 30 and 90 minutes, although they can persist for up to 3 hours.
During an active period, sufferers can experience as few as one attack every other day to one or more daily. In a rare form of cluster headache, known as chronic paroxysmal hemicrania, as many as six attacks per day can occur.
An active period of recurrent cluster attacks typically extends over 4 to 12 weeks.
Headache-free periods last several months to even years.

[For more information on cluster headaches see the Report #99, Cluster Headache.]

WHERE ELSE CAN TENSION HEADACHE SUFFERERS GET INFORMATION?

National Headache Foundation, 428 West St. James Place, 2nd Floor, Chicago, IL 60614-2750. Call (888-NHF-5552) or (312-388-6399) or on the Internet (http://www.headaches.org)

Publishes an excellent quarterly newsletter, Head Lines , containing news, research reports, book reviews, letters and other items.

American Headache Society (http://www.ahsnet.org/) and affiliated organization American Council for Headache Education (http://www.achenet.org/)

19 Mantua Road, Mt. Royal, NJ 08061. Call (856-423-0043)

AHS Publishes the journal Headache (http://ahsnet.org/journal/)

American Academy of Neurology, 1080 Montreal Avenue, St. Paul, Minnesota 55116. Call (651-695-1940) or on the Internet (http://www.aan.com/)

Web site offers good information and provides names of neurologists for specific locations.

National Institute of Neurological Disorders and Stroke, PO Box 5801, Bethesda, MD 20824. Call (301-496-5751) or on the Internet (www.ninds.nih.gov)